Dial 'F' for failure
The NHS recently launched its non-emergency 111 number. Staffed by ‘a team of fully trained advisers’, the scheme’s aim is to quickly and accurately identify the most appropriate medical response to the caller’s needs. What’s important to note is that the ‘fully trained advisors’ aren’t doctors, nurses or paramedics, and do not make clinical decisions themselves. Rather, they use a ‘clinical assessment system’ to assess caller’s needs, and are ‘supported’ by clinical advisors such as doctors, nurses or paramedics. In other words, expertise is positioned away from the front end (where contact occurs with service users), and the operators work their way through menu-driven options, much as in the same way as when you call up your internet service provider to inform them that your connection has crashed again. This type of model builds in failure, and the 111 service is no different. The 111 helpline has attracted a lot of media attention recently, as the following examples demonstrate:
- 30,000 frustrated callers have hung up on the 111 advice line.
- Potentially serious failings, with one incident involving a patient death.
- Confusing advice; lack of response.
As you can see, there have been lots of problems. Why does this failure occur? Bad people? No. It’s the inherently unstable system design, coupled with a management mindset that ensures all the wrong buttons are pressed when the cracks begin to show. Putting aside the potential confusion caused when someone who needs medical help tries to figure out whether their situation is ‘less urgent than 999′, let’s look at the bigger picture and try and understand some of the systemic effects of this type of model. For this, I will use one of my drawings: As you can see, the deficiencies inherent in the 111 model lead to adverse reactions within and around it. Other parts of the system, already subject to their own dysfunctional constraints (such as in A&E) bear the brunt of the badly designed front end. Failure leads to failure and this places further strain on all parts of the system. Faced with a buckling infrastructure, management does what it knows best and reverts to the counterproductive reactions listed, which serve only to intensify the problem. Meanwhile targets are still often met. The antithesis to this type of self-perpetuating mess is simple. You’ve heard it before:
- Adopt a whole system perspective.
- Design the front end to handle predictable demand.
- Ensure expertise is positioned at the point of contact with the service user.
- Remove targets.
This will help both the patient and the system get better. Courtesy of Simon Guilfoyle at Insp Guilfoyle